Provider Demographics
NPI:1811366347
Name:BEVILACQUA, PATRICIA A (BCBA)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:A
Last Name:BEVILACQUA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10606-1218
Mailing Address - Country:US
Mailing Address - Phone:914-290-5797
Mailing Address - Fax:
Practice Address - Street 1:32 GERDES RD
Practice Address - Street 2:
Practice Address - City:NEW CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06840-6708
Practice Address - Country:US
Practice Address - Phone:914-469-6243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1275103K00000X
NY088722877103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1275OtherLICENSE
NY471725852OtherTAX ID
CT1275OtherLICENSE NUMBER